Representative Payee Report, Representative Payee Report, Short Form, Physician's Medical Officer's Statement

ICR 200508-1215-002

OMB: 1215-0173

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
1215-0173 200508-1215-002
Historical Active 200209-1215-002
DOL/ESA
Representative Payee Report, Representative Payee Report, Short Form, Physician's Medical Officer's Statement
Extension without change of a currently approved collection   No
Regular
Approved without change 10/20/2005
Retrieve Notice of Action (NOA) 08/08/2005
  Inventory as of this Action Requested Previously Approved
10/31/2008 10/31/2008 10/31/2005
5,339 0 3,098
5,430 0 3,569
0 0 0

Representative Payee Report (CM-623) and Representative Payee Report, Short Form (CM-623S) are used to ensure that benefits paid to a representative payee are being used for the beneficiary's well-being. Physician's/Medical Officer's Statement (CM-787) is used to determine the beneficiary's capability to manage monthly Black Lung benefits.

None
None


No

1
IC Title Form No. Form Name
Representative Payee Report, Representative Payee Report, Short Form, Physician's Medical Officer's Statement CM-623, CM-623S, CM-787

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 5,339 3,098 0 0 2,241 0
Annual Time Burden (Hours) 5,430 3,569 0 0 1,861 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
08/08/2005


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